YSGG Laser a Peer-Reviewed Publication Written by D

Earn 4 CE credits This course was written for dentists, dental hygienists, and assistants.

Concepts in Laser Periodontal Therapy Using the Er,Cr:YSGG Laser A Peer-Reviewed Publication Written by D. Bradley Dean, DDS, MS

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This course has been made possible through an unrestricted educational grant. The cost of this CE course is $59.00 for 4 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives facilitate the proper training of practitioners in the execution Upon completion of this course, the clinician will be able to of this paradigm shift. do the following: 1. Understand the laser physics, tissue interaction, and Review of Laser Physics and current technology relevant to periodontal treatment. Tissue Interaction 2. Be knowledgeable about treatment algorithms that LASER is an acronym for Light Amplification by Stimu- allow general practioners to evaluate patients requiring lated Emission of Radiation, which is based on theories and periodontal therapies to determine how they can best principles first put forth by Einstein in the early 1900s. The serve their patients’ needs or when they should refer first actual laser system was introduced by Maiman in 1960.2 them to a periodontist. Laser light is a manmade single-photon wavelength. The 3. Understand the concept presented for the successful process of lasing occurs when an excited atom is stimulated to treatment of “site-specific perio” using a laser-assisted, remit a photon before it occurs spontaneously; spontaneous minimally invasive protocol that enables victory in “the emission of light results in unorganized light waves similar to cellular race.” light emitted by a light bulb. Stimulated emission of photons generates a very coherent, collimated, monochromatic ray of Abstract light that is found nowhere else in nature.3 Because laser light Modern laser technology has resulted in treatments that are is so concentrated and focused, it can have a decided effect on less traumatic and more comfortable for patients. Lasers target tissue at a much lower energy level than natural light. present an opportunity for general practitioners to treat cer- The effect of laser light on target tissue is dependent on its tain periodontal conditions and they enable treatment with wavelength, which is determined by the lasing medium inside fewer complications. This also presents an opportunity for the laser device. periodontists to focus on the more complex treatments. When laser light comes into contact with the tissue, it can reflect, scatter, be absorbed, or be transmitted tothe Introduction surrounding tissues. In biological tissue, absorption occurs Is the profession of periodontics in a paradigm shift? Accord- because of the presence of free water molecules, proteins, pig- ing to Dr. Gordon Christensen, in a recent lecture delivered ments, and other organic matter. In the thermal interactions at the World Congress of Minimally Invasive Dentistry, the caused by laser devices, water molecules and their absorption number of patients with periodontal disease that are actually coefficient play a strong role.4 Laser light that is well absorbed being treated by periodontists each year could be declining.1 by water (Er,Cr:YSGG, Er:YAG) is able to mechanically If indeed the case, there may be a combination of the follow- ablate enamel, dentin, and alveolar bone, while laser light ing contributing factors: not well absorbed by water (Diode, Nd:YAG, CO2), results 1. General practitioners have become empowered, to offer a in strong thermal reactions, such as carbonization, charring, wider range of periodontal therapies. This empowerment and melting of organic tissue. is the result of technologies which include soft-tissue and hard-tissue lasers, periodontal scopes and locally-applied Review of Modern Laser Technology antimicrobial agents. Available in Periodontics 2. Patients are having “water-cooler” conversations with The first research of laser use in dentistry surrounded coworkers regarding their experiences and the pain hard-tissue treatments, such as cavity preparation and car- associated with conventional periodontal therapy. ies removal, as a substitute for the conventional drill. The first laser that was the focus of this research was the ruby These trends beg a couple of questions: Have the best laser invented in 1960.5 interests of periodontal patients been taken into consider- In subsequent years, many researchers investigated ation during this paradigm shift? While this shift holds many the hard-tissue applications of lasers, such as argon, CO2, positives for the patient, can the benefits be multiplied with and Nd:YAG. However, these laser systems resulted in proper training and diagnostic/treatment planning skills that major thermal damage to enamel and dentin.6,7 As such, enhance the standard of periodontal care? Is there a risk that researchers focused their attention instead on the soft-tis- general practitioners, armed with new technologies and meth- sue applications of these early-generation high-powered ods for treating periodontal disease, may overestimate their lasers. It was discovered that the CO2 and Nd:YAG lasers newfound capabilities in successfully treating the disease? were capable of excellent soft tissue ablation and hemosta- It is the author’s belief that the aforementioned paradigm sis, which enabled periodontists to use these lasers for the shift was inevitable and is, in fact, good for dentists and their treatment of soft-tissue procedures, such as gingivectomies patients. That said, for the benefit of patients, it is incumbent and frenectomies.8,9,10,11 However, these early lasers had on periodontists, GPs, dental schools, and dental laser manu- such a profound thermal effect on target tissues, includ- facturers to establish treatment parameters and protocols that ing gingival tissue, periodontal ligament, cementum, and

2 www.ineedce.com alveolar bone, that their use for periodontal hard-tissue while achieving results within the standard of care.20,21,22 applications was not promising. Among researchers, most of this emerging information In the 1990’s, an Nd:YAG laser was introduced that would be considered “anecdotal.” That said, however, had a flexible, fiber-optic delivery system, which made multicenter studies are currently underway to prove the it appropriate for selective procedures in the periodontal benefits and applications of the Er,Cr:YSGG laser in peri- pocket, including root surface debridement and pocket odontal therapy as stated in the anecdotal reports. curettage.12 Researchers (including Hibst, et al., Keller, More importantly, it has already been annotated in and Kayano, et al.) discovered that an Erbium:YAG laser, the literature that the Er,Cr:YSGG laser system provides which is highly absorbed by water and hydroxyapatite, a more comfortable patient experience with less trauma was effective in cutting enamel.13 Finally, in the late and post-operative complications, as well as a decreased 1990’s, Eversole, Rizoiu, Kimura, and others published healing time.23,24 Periodontists—whose clinical protocols several notable studies on the Er,Cr:YSGG laser and its can be some of the most precise, invasive, and traumatic in efficacy and safety in cutting soft tissues, enamel, dentin, dental healthcare—should take advantage of these benefits and bone, which all play a significant role in periodontal and be leading the research and implementation of lasers therapy.14,15,16 Because of this versatility, the Er,Cr:YSGG into modern periodontal therapy. This can be achieved by laser was the first all-in-one laser that made the economics creating relationships with local GPs that result in a proac- of providing laser therapy more feasible for the periodon- tive and productive approach to periodontal patient care. tist and general practitioner.17 Over the years, the collective research of hundreds of Review of Treatment Algorithms: individuals has resulted in laser systems that have real and When Should a GP Treat a Periodontal beneficial applications for periodontal care. Current lasers, Condition, and When Should They Refer? wavelengths and applications are listed in Table 1. One way for the periodontist to assist the general dentist The American Academy of Periodontology has issued in choosing the procedures they should or shouldn’t be several position papers on the use of lasers.8,9,11,19 There have attempting with a laser would be for the periodontist to ac- also been several research projects evaluating the benefits tively train referring dentists, thereby empowering them to and disadvantages of using lasers for periodontal treatment. confidently add these treatment protocols to their practice. It should be noted, however, that the findings have focused The benefits are twofold: almost exclusively on the Nd:YAG wavelength. 1. The GPs will be able to deliver laser-assisted The positive results currently emerging in the scientific periodontal therapy as the standard of care for literature on the Er,Cr:YSGG wavelength clearly indicates their community. that periodontists and general practitioners may have a new 2. It allows the periodontist to focus on more complex technology to facilitate the treatment of periodontal disease cases that require a multidisciplinary team approach.

Table 1. Lasers, Wavelengths, and Current Dental Applications Laser Type Wavelength Current Dental Applications Excimer 193 nm to 308 nm Hard tissue ablation, Removal of calculus (not in use at this date) Argon 488 nm to 514 nm Curing of composite materials, Tooth whitening Intraoral soft tissue surgery, Sulcular debridement (subgingival curettage in periodontitis and Carbon Dioxide 10,600 nm peri-implantitis) Intraoral soft tissue surgery, Sulcular debridement (subgingival curettage in periodontitis Nd:YAG 1,064 nm and peri-implantitis), Analgesia, Treatment of dentin hypersensitivity, Pulpotomy, Root canal disinfection, Aphthous ulcer treatment, Removal of gingival melanin pigmentation Caries and calculus detection, Sulcular debridement (subgingival curettage in periodontitis Diode 655 nm to 980 nm and peri-implantitis), Analgesia, Treatment of dentin hypersensitivity, Pulpotomy, Root canal disinfection, Aphthous ulcer treatment, Removal of gingival melanin pigmentation Caries removal and cavity preparation, Modification of enamel and dentin surfaces, Intraoral general and implant soft tissue surgery, Sulcular debridement (subgingival curettage in peri- Er,Cr:YSGG 2,780 nm odontitis and peri-implantitis), Scaling of root surfaces, Osseous surgery, Treatment of dentin hypersensitivity, Analgesia, Pulpotomy, Root canal treatment and disinfection, Aphthous ulcer treatment, Removal of gingival melanin/metal-tattoo pigmentation Same as Er,Cr:YSGG, although coagulative capabilities are more limited and studies have Er:YAG 2,940 nm shown inefficient delivery energy at the tissue surface.18

www.ineedce.com 3 Table 2. Essential Periodontal Procedures and Algorithms for Determining if a GP Should Treat or Refer CDT-4 Description of the procedure Procedure Code and who should treat Clinical Photograph

The surgical removal of a soft-tissue lesion. Soft-tissue biopsy D7286 A simple procedure, especially with a laser, (fibroma, mucoseal, etc.) that can easily be treated by the GP and rarely requires sutures.25 (Fig. 1)

Fig. 1

Utilization of a laser to treat oral ulcerations for Soft tissue band-aid for relief of pain herpetic lesion, aphthous D4999 A simple procedure, especially with a laser, ulcer, split lip, etc. that can easily be treated by the GP and rarely requires sutures.14 (Fig. 2)

Fig. 2

The surgical removal or repositioning of a frenum; this procedure is performed to enhance the stability of a corrected disatema or to Frenectomy D7960 relieve a tongue tie A simple procedure, especially with a laser, that can easily be treated by the GP and rarely requires sutures.14 (Fig. 3)

Fig. 3

A surgical procedure designed to sever the gingival and/or transseptal periodontal fibers Circumferential around a tooth, usually to reduce the tendency Supracrestal D7291 for relapse of corrected tooth rotations. Fiberotomy A simple procedure, especially with a laser, that can easily be treated by the GP and rarely requires sutures.14 (Fig. 4)

Fig. 4

Involves the excision of the soft tissue when there is asymmetrical or unaesthetic gingival architecture. A simple procedure, especially with a laser, Gingivectomy D4210, that can easily be treated by the GP and rarely D4211 requires sutures. Care must be taken to avoid violation of the biologic width. (See Laser-assisted crown lengthening below).14 (Fig. 5) Fig. 5

4 www.ineedce.com CDT-4 Description of the procedure Procedure Code and who should treat Clinical Photograph

Functional: This procedure is employed on a single tooth to allow a restorative procedure or crown when there is little or no tooth structure exposed to the oral cavity and the Fig. 6. final restorative margins would violate the biologic width.26,27

Cosmetic: This procedure is performed in the aesthetic zone to facilitate an ideal gingival architecture and may involve the recontouring of hard and soft tissue in order to prevent violation of biologic width.26,27 (Fig. 6)

Proper diagnosis and treatment planning are required to differentiate the complexity of the treatment required for both functional Fig. 7. and cosmetic crown lengthening. Crown Lengthening- D4249 Functional/Cosmetic Step 1. Sounding to bone to establish the height of the osseous crest in relationship to the planned gingival height. (Fig. 7)

Step 2. The Er,Cr:YSGG laser is used to recontour the soft tissue and the osseous tissue, if needed, with a minimally invasive approach. In some cases, a flap is required to properly recontour the bone in which case the laser would assist in the completion of the procedure. Fig. 8.

Step 3. Re-sound down to the bone to make sure the biologic width has not been vio- lated. (Fig. 8, Fig. 9)

With training, GPs may choose to perform these procedures on a case-by-case basis or elect to refer more complex cases.

Fig. 9

www.ineedce.com 5 Properly implemented, this is a true “win-win-win” for light, epithelium is clearly the “enemy” of a periodontal the patient, GP, and periodontist. therapist as it relates to the healing that occurs follow- The procedures discussed in Table 2 are based on the ing conventional treatment of periodontitis. If epithelial author’s utilization of an Er,Cr:YSGG all-tissue laser (Wa- tissue is not properly managed, rapid growth may result terlase MD™, BIOLASE Technology, Inc., San Clemente, in unpredictable periodontal regeneration, i.e. long-junc- California, USA). tional epithelium30 (Fig. 11). Conventional site-specific perio treatment outcomes Er,Cr:YSGG Laser-Assisted, Site-Specific can be improved by creating a biologic advantage for con- Perio and Cellular Kinetics nective tissue and bone. This can be facilitated by a surgi- To better understand why the Er,Cr:YSGG laser is so ef- cally placed membrane that excludes epithelial cells from fective in the treatment of site-specific perio, (Fig. 16) we the healing process, which results in regeneration. “Guided need to first grasp the concept of cellular kinetics and the tissue regeneration,” as this technique is called, is a proven “cellular race.” Unlike the Nd:YAG laser, which relies on and widely used technique31 (Fig. 12 and Fig. 15). significant penetration into the soft tissue28 to achieve the It may be possible to achieve the same process of cel- desired results, the Er,Cr:YSGG laser ablates soft tissue by lular exclusion to enhance the biologic response using a selectively removing a few cell layers at a time29. Because of laser-assisted, minimally invasive technique called “epi- this, the Er,Cr:YSGG laser allows a periodontist to achieve thelial ablation” (Figs. 13–15). the successful results that had been previously achieved First, the root surfaces of the teeth to be treated are only by using more aggressive surgical techniques. thoroughly debrided of any calculus, plaque or bacteria. This paradigm shift in treatment is not based on the This is completed with a combination of hand instrumen- Er,Cr:YSGG replacing traditional periodontal therapies tation and use of the Er,Cr:YSGG laser (Fig. 17–19). The altogether; rather it is based simply on using a new instru- inside of the periodontal pocket is de-epithelialized using ment with proven results to manipulate the tissue inter- the laser (Fig. 20). This de-epithelialization is continued faces and manage cellular kinetics. onto the buccal gingival tissue approximately 5mm be- yond the free gingival margin. If a bony defect is present, What is Site-Specific Perio? the granulation tissue is removed using the laser. A bone As previously discussed, the empowerment of GPs to treat grafting material or a tissue stimulant (ameliogens) may be a significant portion of periodontal disease in their own applied to enhance the result.32 The goals of a connective practices is achieved with proper training and understand- tissue re-attachment and resolution of the bony defect ing of situational algorithms accomplishes two goals: 1) As can be realized with minimal discomfort to the patient, no a result of the information provided by the periodontist, sutures and a reduced healing time (Fig. 21). the GPs enjoy a new source of revenue. This new revenue In the event a flap is required, the tissue on either side stream will ultimately result in a productive, loyal relation- of the incision is de-epithelialized such that no scarring ship between a GP and a periodontist; 2) It reduces the will occur following healing. The cellular race is won on amount of generalized periodontal disease that is referred behalf of the tooth when the three cell types repopulate the and instead allows GPs to refer only those sites, i.e. ‘site- periodontal defect in the proper proportion along the root specific perio,’ that have not responded to the treatments surfaces that existed in health (Fig. 21). outlined in the algorithms. Utilizing the Er,Cr:YSGG laser in conjunction with Conclusion other emerging technologies and bone grafting material as Although the state of periodontics is undergoing a para- required allows the periodontist to treat the ‘site-specific digm shift, the advent of new laser technology provides perio’ in a minimally invasive manner. periodontists and general practitioners with an instru- ment that allows minimally invasive, more comfortable What is Cellular Kinetics? treatment within the standard of care. The treatment Periodontal regeneration is defined as the replacement capabilities involve the successful and effective treat- of lost connective tissue and supporting bony structure ment of traditional procedures, such as gingivectomies, is characterized by the dynamic interaction of the three frenectomies, soft tissue lesions; advanced procedures, tissue types in the oral cavity: epithelium (Fig. 10a), con- such as functional or cosmetic crown lengthening; and nective tissue (Fig. 10b) and bone (Fig. 10c). It has been site-specific therapies for residual periodontal conditions. shown that the protective nature of epithelium causes it With laser technology more accessible than ever before, it to travel much faster to repopulate a healing periodon- is important that periodontists and general practitioners tal wound than the other two tissue types. Connective provide optimum periodontal therapy within the standard tissue cells come in second in “the race” with bone of care. This can be achieved with a clear understanding of and periodontal ligament tissue cells being last. In this basic laser periodontal procedures that can be performed at

6 www.ineedce.com Figure 10. The “cellular race” involves Figure 11. When the three tissue types Figure 12. The periodontal defect with three tissue types: epithelium (A), con- are not properly managed, scarring a membrane placed (D) to exclude epi- nective tissue (B), and bone/PDL (C). will occur. Pictured is a healed wound thelial cells during tissue regeneration. Pictured is an incision compatible with that is compatible with the formation that associated with the treatment of of long-junctional epithelium. periodontal disease.

Figure 13. Ablation of the epithelial Figure 14. Ablation of the connective Figure 15. Pictured is normal healing layer using the Er,Cr:YSGG laser to tissue using the Er,Cr:YSGG laser to compatible with connective tissue exclude epithelial cells during tissue exclude connective tissue cells during reattachment and bone regeneration in regeneration. tissue regeneration. the treatment of site-specific perio.

Figure 16. Site-specific periodontal Figure 17. Hand scaling. Figure 18. Laser-assisted scaling using disease. the Er,Cr:YSGG laser.

Figure 19. Thoroughly debrided root Figure 20. De-epithelialization using Figure 21. Normal healing has occurred surface. the Er,Cr:YSGG laser. with connective tissue reattachment and bone regeneration.

www.ineedce.com 7 the GP level, and those that should be referred to a trained 24 Wang X, Zhang C, Matsumoto K. In vivo study of the healing processes that occur in the jaws of rabbits following perforation by an Er,Cr:YSGG laser. Lasers Med Sci 2005: 20(1): 21–7. and informed laser periodontist. 25 Walinski CJ. Irritation fibroma removal: a comparison of two laser wavelengths. Gen Dent. 2004 If you are considering a purchase of a laser system, it is May–June: 52(3): 236–8. critical to consider laser manufacturers that heavily invest 26 Kois, JC. The Gingiva is Red Around My Crown — A Differential Diagnosis Dent Econ 1993: 4: in training their end users, whether through CE courses 101–105. 27 Kois, JC. Altering Gingival Levels: The Restorative Connection I. Biological Variables J Ethet Dent and seminars, larger-scale laser symposia, or a network 1994: 6: 3–9. of independent clinical trainers. That said, periodontists, 28 Dederich DN. Laser curettage: an overview. Compend Contin Educ Dent. 2002 November: 23 dental schools, and dental-laser manufacturers should es- (11A): 1097–103. tablish treatment parameters and protocols that facilitate 29 Kaufmann R, Hartmann A, Hibst R. Cutting and skin-ablative properties of pulsed mid-infrared laser surgery. J Dermatol Surg Oncol 1994 February: 20(2): 112–8. the proper training of practitioners to successfully execute 30 Blass JL, Lite T. Gingival healing following surgical curettage: A histopathologic Study. NY Dental this paradigm shift for the benefit of patients. J 1959: 25:127 31 Karring T, Nyman S, Gottlow J, Laurell L. Development of the biologic concept of guided tissue References regeneration — animal and human studies. J Periodontol 2000, 1993; 1:26–35. 1 Christensen, G. Keynote address: Trends in minimally invasive dentistry. Conference proceedings, 32 Hammarstrom L. Enamel matrix, cementum development and regeneration. J Clin Periodontol World Congress of Minimally Invasive Dentistry, Aug 2005, San Diego, California, USA. 1997: 4:658. 2 Maiman TH. Stimulated optical radiation in ruby. Nature 1960: 187: 493–494. 3 Clayman L, Kuo P. Lasers in Maxillofacial Surgery and Dentistry. New York: Thieme, 1997: 1–9. 4 Niemz MH. Laser-tissue Interaction. Fundamentals and Applications. Berlin: Springer-Verlag, Author Profile 1996: 64–65. 5 Goldman L, Hornby P, Meyer R, Goldman B. Impact of the laser on dental caries. Nature 1964: D. Bradley Dean, DDS, MS 25: 417. 6 Frentzen M, Braun A, Aniol D. Er:YAG laser scaling of diseased root surfaces. J Periodontol 2002: Dr. Bradley Dean, who was recently vot- 73: 524–530. ed one of the top periodontists in Texas, 7 Wigdor HA, Walsh JT Jr, Featherstone JD, Visuri SR, Fried D, Waldvogel JL. Lasers in dentistry. received his undergraduate education Lasers Surg Med 1995:16: 103–133. from Texas A&M University and his 8 AAP (The American Academy of Periodontology). The Research, Science and Therapy Committee of the American Academy of Periodontology, Gottsegen R, Ammons WF, Aoki et al. WF. Lasers in DDS from Baylor College of Dentistry, Periodontics (position paper). Chicago: AAP, 1991: 1–5. in Dallas, Tex. In Dallas, he also com- 9 AAP (The American Academy of Periodontology). The Research, Science and Therapy Committee pleted a fellowship in oral medicine and of the American Academy of Periodontology, Cohen RE, Ammons W. Lasers in periodontics a Masters Degree from the department of periodontics. Dr. (position paper). J Periodontol 1996: 67: 826–830. 10 AAP (The American Academy of Periodontology). The Research, Science and Therapy Committee Dean lectures nationally and internationally and has writ- of the American Academy of Periodontology, Cohen RE, Ammons WF. Revised by Rossman JA. ten scientific articles on topics such as tissue regeneration, Lasers in periodontics (Academy report). J Periodontol 2002: 73: 1231–1239. bone regeneration, and cosmetic implant dentistry. He is 11 Pick RM, Colvard MD. Current status of lasers in soft tissue dental surgery. J Periodontol 1993: 64: currently one of the pioneers in developing periodontal laser 589–602. 12 Myers TD. Lasers in dentistry. J Am Dent Assoc 1991: 122: 47–50. techniques that provide his patients a minimally invasive 13 Kayano T, Ochiai S, Kiyono K, Yamamoto H, Nakajima S, Mochizuki T. Effects of Er:YAG laser and virtually pain-free treatment of their periodontal condi- irradiation on human extracted teeth [in Japanese, English abstract]. Kokubyo Gakkai Zasshi tions. He is a visiting lecturer at Baylor College of Dentistry 1989: 56: 381–392. and Collin County Community College Hygiene School. He 14 Rizoiu IM, Eversole LR, Kimmel AI. Effects of an erbium, chromium:yttrium, scandium, gallium, garnet laser on mucocutanous soft tissues. Oral Surg Oral Med Oral Pathol Oral Radiol Endod is a Diplomate of the American Academy of Periodontology 1996: 82:386–95. as well as an active member in the American Dental As- 15 Eversole LR, Rizoiu IM. Preliminary investigations on the utility of an Er,Cr:YSGG laser. CDA Journal sociation, the Texas Dental Association, the Dallas County 1995: 12: 41–47. Dental Society, and the North Texas Dental Society. 16 Kimura Y, Da-Guang Y, et al. Effects of an erbium,chromium:YSGG laser irradiation on canine mandibular bone. J Periodontol 2001: 72: 1178–1182. 17 Dederich D, Bushick RD. Lasers in dentistry: Separating science from hype. J Am Dent Assoc 2004: Acknowledgement 135: 204. The author wishes to thank Patient Care Suite, Markham, 18 Straßl M, Üblacker B, Bäcker A, Beer F, Moritz A, Wintner E. Comparison of the emission Ontario, for Figures 16–21 and cover illustrations. Patient characteristics of three erbium laser systems — a physical case report, J Oral Laser Appl 2004; 4: 263–270. Care Suite may be reached at 800-263-5892. 19 AAP (The Academy of Periodontology). The Research, Science and Therapy Committee of the American Academy of Periodontology. Statement regarding use of dental lasers for excisional Disclaimer new attachment procedure (ENAP). Released by the AAP in August 1999. The author of this course has no commercial ties with the 20 Schoop U, Kluger W, Moritz A, et al. Sperr W. Bactericidal effect of different laser systems in the deep layers of dentin. Lasers Surg Med 2004: 35 (2):111–6. sponsors or the providers of the unrestricted educational 21 Miller RJ. Treatment of the contaminated implant surface using the Er,Cr:YSGG laser. Implant Dent grant for this course. 2004 June: 13 (2): 165–70. 22 Lee CY. Procurement of autogenous bone from ramus with simultaneous the mandibular third- Reader Feedback molar removal for bone grafting using the Cr:YSGG laser: a preliminary report. J Oral Implantol 2005: 31(1): 32–8. We encourage your comments on this or any PennWell course. 23 Lioubavina H. Lasers in dentistry. 5. The use of lasers in periodontology [in Dutch, abstract in For your convenience, an online feedback form is available at English]. Ned Tijdschr Tandheelkd. 2002 August: 109 (8): 286–292. www.ineedce.com.

8 www.ineedce.com Questions

1. The first laser used in dentistry in the 11. Early lasers had a profound thermal 21. The CDT-4 code for a Frenectomy 1960’s was a _____ laser. effect on target tissues. is ____. a. Garnet a. True a. D7291 b. Diamond b. False b. D7286 c. Emerald c. D4210 d. Ruby 12. Argon lasers were used to cure d. D7960 composite materials. 2. Thomas Edison introduced the first a. True 22. The CDT-4 code for a Crown theories on lasers. b. False a. True Lengthening is _____. b. False 13. The Carbon Dioxide laser has a a. D4249 b. D7286 wavelength of _____ . 3. LASER is an acronym for _____ . c. D4210 a. 488 nm a. Light Amplification by Stimulated Emission d. D4999 of Radiation b. 2,100 nm b. Light Assisted Stimulated Energy c. 10,600 nm 23. All crown lengthening procedures and Radiation d. 337 nm require the reflection of a flap. c. Light Amplification by Stimulated Emission 14. The Er,Cr:YSGG laser has a a. True of Radar wavelength of _____ . b. False 4. The author believes that the current a. 514 nm 24. The three tissues that are involved in b. 2,780 nm periodontal paradigm shift is bad for the cellular race are: dentists and their patients. c. 193 nm d. 2,940 nm a. Epithelium, Connective Tissue, and PDL a. True b. Connective Tissue, Bone, and PDL b. False 15. The Nd:YAG laser can be used for c. Epithelium, Connective Tissue, and Bone 5. Laser light is a man-made single- both hard and soft tissue. _____ wavelength. a. True 25. In normally occurring cellular a. Atom b. False kinetics, _____ is the “enemy” of b. Proton the periodontist. c. Neutron 16. The Er,Cr:YSGG laser can be used a. Bone d. None of the above for both hard and soft tissue. b. Epithelium a. True c. Connective Tissue 6. Spontaneous emission of light results b. False d. Periodontal Ligament in unorganized light waves. e. All of the above. a. True 17. The early position papers published b. False by the American Academy of Peri- 26. The goal of site-specific perio odontology were primarily focused 7. When laser light comes in contact is to achieve a long-junctional on the _____ laser. with tissue, it can _____ . epithelium attachment. a. Er,Cr:YSGG a. Reflect a. True b. Nd:YAG b. Scatter b. False c. Be absorbed c. Er:YAG d. All of the above d. Diode 27. When the tissues are de-epithelialized to facilitate cellular kinetics, the 18. It has been demonstrated in the 8. Laser devices that are well absorbed recommended distance is _____. literature that the Er,Cr:YSGG by water include _____. a. 3 mm laser has the following benefits for a. Er,Cr:YSGG b. 4 mm b. Nd:YAG the patient: c. 5 mm c. Argon a. More comfort d. 6 mm d. Diode b. Less trauma e. Both b & c c. Decreased healing time 28. When considering the purchase f. None of the above d. All of the above of a laser, training is not important 9. Lasers not well absorbed by water 19. The surgical procedure designed to for successful implementation in result in: sever the gingival and/or transseptal your practice. a. Carbonization periodontal fibers around a tooth is a. True b. Charring b. False c. Melting of organic tissue called _____. d. Both b & c a. Frenectomy 29. The author believes that initial b. Gingivectomy e. Both a & b root debridement can be accom- f. All of the above c. Circumferential Supracrestal Fiberotomy d. Soft-Tissue Biopsy plished with a combination of hand 10. The Er,Cr:YSGG laser does NOT scaling and laser scaling. have FDA clearance for, and is not 20. The procedure that involves the a. True recommended for which one of the excision of soft tissue only when b. False there is asymmetrical or unaesthetic following ____? 30. In cellular kinetics, scarring oc- a. Soft Tissue Biopsy gingival architecture is called _____. b. Periodontal Treatment a. Gingivectomy curs as a result of the invagination c. Cavity Preparations b. Crown Lengthening-Cosmetic of the epithelium. d. Cutting Amalgam c. Frenectomy a. True e. Cutting Bone d. Soft-Tissue Biopsy b. False www.ineedce.com 9 ANSWER SHEET Concepts in Laser Periodontal Therapy Using the Er,Cr:YSGG Laser

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Mail completed answer sheet to Educational Objectives Academy of Dental Therapeutics and Stomatology, 1. Understand the laser physics, tissue interaction, and current laser technology relevant to the treatment of A Division of PennWell Corp. periodontal disease. P.O. Box 116, Chesterland, OH 44026 or fax to: (440) 845-3447 2. Be knowledgeable about treatment algorithms that allow general practioners to evaluate patients requiring periodontal therapies to determine how they can best serve their patients’ needs or when they should refer them to a periodontist. For immediate results, go to www.ineedce.com 3. Understand the concept presented for the successful treatment of “site-specific perio” using a laser-assisted, minimally and click on the button “Take Tests Online.” Answer sheets can be faxed with credit card payment to invasive protocol that enables victory in “the cellular race.” (440) 845-3447, (216) 398-7922, or (216) 255-6619. Payment of $59.00 is enclosed. Course Evaluation (Checks and credit cards are accepted.) Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. If paying by credit card, please complete the following: MC Visa AmEx Discover 1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No Acct. Number: ______Objective #2: Yes No Exp. Date: ______2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 Charges on your statement will show up as PennWell

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6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0

7. Was the overall administration of the course effective? 5 4 3 2 1 0

8. Do you feel that the references were adequate? Yes No

9. Would you participate in a similar program on a different topic? Yes No

10. If any of the continuing education questions were unclear or ambiguous, please list them. ______

11. Was there any subject matter you found confusing? Please describe. ______

12. What additional continuing dental education topics would you like to see? ______AGD Code 135

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

AUTHOR DISCLAIMER INSTRUCTIONS COURSE CREDITS/COST RECORD KEEPING The author of this course has no commercial ties with the sponsors or the providers of All questions should have only one answer. Grading of this examination is done All participants scoring at least 70% (answering 21 or more questions correctly) on the PennWell maintains records of your successful completion of any exam. Please contact our the unrestricted educational grant for this course. manually. Participants will receive confirmation of passing by receipt of a verification examination will receive a verification form verifying 4 CE credits. The formal continuing offices for a copy of your continuing education credits report. This report, which will list form. Verification forms will be mailed within two weeks after taking an examination. education program of this sponsor is accepted by the AGD for Fellowship/Mastership all credits earned to date, will be generated and mailed to you within five business days SPONSOR/PROVIDER credit. Please contact PennWell for current term of acceptance. Participants are urged to of receipt. This course was made possible through an unrestricted educational grant. No EDUCATIONAL DISCLAIMER contact their state dental boards for continuing education requirements. PennWell is a manufacturer or third party has had any input into the development of course content. The opinions of efficacy or perceived value of any products or companies mentioned California Provider. The California Provider number is 3274. The cost for courses ranges CANCELLATION/REFUND POLICY All content has been derived from references listed, and or the opinions of clinicians. in this course and expressed herein are those of the author(s) of the course and do not from $49.00 to $110.00. Any participant who is not 100% satisfied with this course can request a full refund by Please direct all questions pertaining to PennWell or the administration of this course to necessarily reflect those of PennWell. contacting PennWell in writing. Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or [email protected]. Many PennWell self-study courses have been approved by the Dental Assisting National Completing a single continuing education course does not provide enough information Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet © 2008 by the Academy of Dental Therapeutics and Stomatology, a division COURSE EVALUATION and PARTICIPANT FEEDBACK to give the participant the feeling that s/he is an expert in the field related to the course DANB’s annual continuing education requirements. To find out if this course or any other of PennWell We encourage participant feedback pertaining to all courses. Please be sure to complete the topic. It is a combination of many educational courses and clinical experience that PennWell course has been approved by DANB, please contact DANB’s Recertification survey included with the course. Please e-mail all questions to: [email protected]. allows the participant to develop skills and expertise. Department at 1-800-FOR-DANB, ext. 445.

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